A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify
which of the following findings as a manifestation of fluid volume excess?
b. Distended neck veins
A nurse is caring for a client who has hyponatremia and is receiving an infusion of a prescribed
hypertonic solution. Which of the following findings should indicate to the nurse that the
treatment is effective?
b. Improved cognition
A nurse is teaching a client who has a new prescription for a nitroglycerin transdermal patch.
Which of the following instructions should the nurse include?
d. "Remove the patch prior to going to bed."
A nurse is reviewing her laboratory results of a client who has a prescription for sodium
polystyrene sulfonate (Kayexalate) every 6 hr. which of the following should the nurse report to
the provider?
d. Potassium 5.2 mEq/L
A nurse is caring for a client who has tuberculosis and is taking isoniazid and rifampin. Which of
the following outcomes indicates that the client is adhering to the medication regimen?
a. The client has a negative sputum culture
A client is caring for a client who develops an anaphylactic reaction to IV administration. After
assessing the client's respiratory status and stopping the medication infusion. Which of the
following actions should the nurse take next?
d. Administer epinephrine IM
A nurse is caring for a client who is taking sertraline and reports a desire to begin taking
supplements. Which of the following supplements should the nurse advise the client to avoid?
a. St. John's Wort
A nurse is caring for a client who has heart failure and a new prescription for lisinopril. For
which of the following adverse effects should the nurse monitor when administering lisinopril?
d. Hypotension
A nurse is assessing a client who is receiving heparin IV continuous IV. The client has an PPT of
90 seconds. They should monitor the client for which of the following changes in their vital
signs?
,d. Increased blood pressure
A nurse is preparing to administer medication to a client and discovers a medication error. The
nurse should recognize that which of the following staff members is responsible for completing
an incident report?
b. The nurse who identifies the error
A nurse is planning care for a client who is receiving morphine via continuous epidural infusion.
The nurse should monitor the client for which of the following?
a. Pruritus - Sign of allergic reaction to morphine
A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the
nurse should take. (Move the steps into the box on the right, placing them in the order of
performance. Use all the steps.)
a. Obtain the client's apical heart rate
b. Remove the medication from the dispensing system
c. Open the medication package
d. Compare the client's wristband to the medication administration record
e. Document administration of the medication
A nurse is reviewing the medical record of an adult client who has a fever and a prescription for
acetaminophen. Which of the following findings should the nurse identify as a contraindication
for receiving this medication?
Alcohol use disorder
Chronic kidney disease?(if in selection)
A home health nurse is visiting a client who has heart failure and a prescription for furosemide.
The nurse identifies that the client has gained 2.5 kg (5 lb.) since the last visit 2 days ago. Which
of the following actions should the nurse take first?
c. Determine medication adherence by the client
A nurse is preparing to administer the initial dose of penicillin G IM to a client. The nurse should
monitor for which of the following as an indication of an allergic reaction following the
injection?
a. Urticaria
A nurse is teaching a client who has angina a new prescription for sublingual nitroglycerin
tablets. Which of the following instructions should the nurse include in the teaching?
c. "Keep the tablets at room temperature in their original glass bottle."
, A nurse is providing teaching to a client who has a new prescription for theophylline, a
sustained-released capsule. Which of the following statements by the client indicates an
understanding of the teaching?
a. "I can take my medication in the morning with my coffee."
A nurse is mixing regular insulin and NPH insulin in the same syringe prior to administering it to
client who has diabetes mellitus following actions should the nurse take first?
c. Inject air into the NPH vial
A nurse is preparing to administer subcutaneous heparin to a client. Which of the following
should the nurse take?
d. Insert the needle at least 5 cm (2 in) from the umbilicus
A nurse is caring for a client who has a prescription for amoxicillin. Which of the following
findings indicates the client is experiencing an allergic reaction?
c. Laryngeal edema
A nurse is teaching a newly licensed nurse about medication reconciliation. The nurse should
instruct the newly licensed nurse to perform medication reconciliation for which of the
following?
c. A client who is transferal to a step-down unit
A nurse is reviewing the laboratory values of a client who is taking atorvastatin. Which of the
following laboratory values indicates the treatment has been effective?
d. LDL 120 mg/dL
A nurse is receiving a medication prescription by telephone from a provider. The provider states,
"Administer 6 milligrams of morphine IV push every 3 hours as needed for acute pain." How
should the nurse transcribe the prescription in the client's medical record?
a. Morphine 6 mg IV push every 3 hr PRN acute pain
A nurse is assessing a client's IV infusion site and notes that the site is cool and edematous.
Which of the following actions should the nurse take?
d. Apply a warm, moist compress
A nurse is providing teaching to a client who has a new prescription for clozapine. Which of the
following statements should the nurse include in the teaching?
c. "Notify your provider if you develop a fever while taking this medication."
which of the following findings as a manifestation of fluid volume excess?
b. Distended neck veins
A nurse is caring for a client who has hyponatremia and is receiving an infusion of a prescribed
hypertonic solution. Which of the following findings should indicate to the nurse that the
treatment is effective?
b. Improved cognition
A nurse is teaching a client who has a new prescription for a nitroglycerin transdermal patch.
Which of the following instructions should the nurse include?
d. "Remove the patch prior to going to bed."
A nurse is reviewing her laboratory results of a client who has a prescription for sodium
polystyrene sulfonate (Kayexalate) every 6 hr. which of the following should the nurse report to
the provider?
d. Potassium 5.2 mEq/L
A nurse is caring for a client who has tuberculosis and is taking isoniazid and rifampin. Which of
the following outcomes indicates that the client is adhering to the medication regimen?
a. The client has a negative sputum culture
A client is caring for a client who develops an anaphylactic reaction to IV administration. After
assessing the client's respiratory status and stopping the medication infusion. Which of the
following actions should the nurse take next?
d. Administer epinephrine IM
A nurse is caring for a client who is taking sertraline and reports a desire to begin taking
supplements. Which of the following supplements should the nurse advise the client to avoid?
a. St. John's Wort
A nurse is caring for a client who has heart failure and a new prescription for lisinopril. For
which of the following adverse effects should the nurse monitor when administering lisinopril?
d. Hypotension
A nurse is assessing a client who is receiving heparin IV continuous IV. The client has an PPT of
90 seconds. They should monitor the client for which of the following changes in their vital
signs?
,d. Increased blood pressure
A nurse is preparing to administer medication to a client and discovers a medication error. The
nurse should recognize that which of the following staff members is responsible for completing
an incident report?
b. The nurse who identifies the error
A nurse is planning care for a client who is receiving morphine via continuous epidural infusion.
The nurse should monitor the client for which of the following?
a. Pruritus - Sign of allergic reaction to morphine
A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the
nurse should take. (Move the steps into the box on the right, placing them in the order of
performance. Use all the steps.)
a. Obtain the client's apical heart rate
b. Remove the medication from the dispensing system
c. Open the medication package
d. Compare the client's wristband to the medication administration record
e. Document administration of the medication
A nurse is reviewing the medical record of an adult client who has a fever and a prescription for
acetaminophen. Which of the following findings should the nurse identify as a contraindication
for receiving this medication?
Alcohol use disorder
Chronic kidney disease?(if in selection)
A home health nurse is visiting a client who has heart failure and a prescription for furosemide.
The nurse identifies that the client has gained 2.5 kg (5 lb.) since the last visit 2 days ago. Which
of the following actions should the nurse take first?
c. Determine medication adherence by the client
A nurse is preparing to administer the initial dose of penicillin G IM to a client. The nurse should
monitor for which of the following as an indication of an allergic reaction following the
injection?
a. Urticaria
A nurse is teaching a client who has angina a new prescription for sublingual nitroglycerin
tablets. Which of the following instructions should the nurse include in the teaching?
c. "Keep the tablets at room temperature in their original glass bottle."
, A nurse is providing teaching to a client who has a new prescription for theophylline, a
sustained-released capsule. Which of the following statements by the client indicates an
understanding of the teaching?
a. "I can take my medication in the morning with my coffee."
A nurse is mixing regular insulin and NPH insulin in the same syringe prior to administering it to
client who has diabetes mellitus following actions should the nurse take first?
c. Inject air into the NPH vial
A nurse is preparing to administer subcutaneous heparin to a client. Which of the following
should the nurse take?
d. Insert the needle at least 5 cm (2 in) from the umbilicus
A nurse is caring for a client who has a prescription for amoxicillin. Which of the following
findings indicates the client is experiencing an allergic reaction?
c. Laryngeal edema
A nurse is teaching a newly licensed nurse about medication reconciliation. The nurse should
instruct the newly licensed nurse to perform medication reconciliation for which of the
following?
c. A client who is transferal to a step-down unit
A nurse is reviewing the laboratory values of a client who is taking atorvastatin. Which of the
following laboratory values indicates the treatment has been effective?
d. LDL 120 mg/dL
A nurse is receiving a medication prescription by telephone from a provider. The provider states,
"Administer 6 milligrams of morphine IV push every 3 hours as needed for acute pain." How
should the nurse transcribe the prescription in the client's medical record?
a. Morphine 6 mg IV push every 3 hr PRN acute pain
A nurse is assessing a client's IV infusion site and notes that the site is cool and edematous.
Which of the following actions should the nurse take?
d. Apply a warm, moist compress
A nurse is providing teaching to a client who has a new prescription for clozapine. Which of the
following statements should the nurse include in the teaching?
c. "Notify your provider if you develop a fever while taking this medication."
